Real-time intraoperative confocal laser endomicroscopy with on-site neuropathologist consultation for glioma margin
Sun Mo Nam1, Kyuyoung Kim2, Jae-Kyung Won3
1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul.
Background:
Achieving maximal safe resection in glioma surgery requires accurate real-time margin assessment, yet existing technologies have limitations. Fluorescence-guided surgery shows limitations at infiltrative margins, while frozen section analysis requires 20-45 minutes per specimen. Confocal laser endomicroscopy (CLE) is an emerging in vivo imaging technology that enables real-time cellular-resolution tissue examination in situ.
Observations:
The authors present a case demonstrating integration of CLE with on-site neuropathologist collaboration for real-time intraoperative diagnosis. A 53-year-old woman with left frontotemporal high-grade glioma underwent surgery with systematic examination of five locations using CLE. The collaborative workflow enabled rapid tissue assessment (mean 95 seconds per site) with immediate expert interpretation. Critically, high-grade glioma was detected at a site with complete absence of 5-aminolevulinic acid fluorescence (spot 4), demonstrating CLE's capability to identify tumor infiltration beyond fluorescence-guided boundaries and enabling extended resection.
Lessons:
Integrating CLE with on-site pathologist consultation creates an effective paradigm for real-time margin assessment, addressing the 30%-40% false-negative rate of fluorescence guidance. This collaborative approach is immediately implementable at centers with neuropathology expertise and establishes a foundation for future telepathology and artificial intelligence-assisted diagnostic platforms. https://thejns.org/doi/10.3171/CASE25890.
